Trochlear groove osteochondritis dissecans of the knee patellofemoral joint

Understanding Osteochondritis Dissecans: A Narrative Review of the Disease Commonly Affecting Children and Adolescents

BACKGROUND

Osteochondritis dissecans (OCD) is a joint disorder predominantly affecting the knee, elbow, and ankle of children and adolescents. This comprehensive review delves into the epidemiology, etiology, clinical manifestations, diagnostic approaches, and treatment of OCD.

RESULTS

The most common cause of OCD is repetitive microtrauma, typically associated with sports activities, alongside other significant factors such as genetic predisposition, ischemia, and obesity. In early stages or when lesions are small, OCD often presents as non-specific, vaguely localized pain during physical activity. As the condition progresses, patients may experience an escalation in symptoms, including increased stiffness and occasional swelling, either during or following activity. These symptom patterns are crucial for early recognition and timely intervention. Diagnosis in most cases is based on radiographic imaging and magnetic resonance imaging. Nonsurgical treatment of OCD in young patients with open growth plates and mild symptoms involves activity restriction, immobilization methods, and muscle strengthening exercises, with a return to sports only after symptoms are fully resolved and at least six months have passed. Surgical treatment of OCD includes subchondral drilling in mild cases. Unstable lesions involve methods like restoring the joint surface, stabilizing fractures, and enhancing blood flow, using techniques such as screws, anchors, and pins, along with the removal of fibrous tissue and creation of vascular channels. The specifics of OCD treatment largely depend on the affected site.

CONCLUSIONS

This synthesis of current research and clinical practices provides a nuanced understanding of OCD, guiding future research directions and enhancing therapeutic strategies.

High rates of return to sport following management of osteochondritis dissecans of the femoral trochlea: A systematic review

PURPOSE

To summarize management strategies and associated clinical outcomes in patients with osteochondritis dissecans (OCD) of the femoral trochlea.

METHODS

Three databases were searched from inception to 2 October 2023, for studies describing outcomes posttreatment for femoral trochlear OCD. The authors adhered to the preferred reporting items for systematic reviews and meta-analyses and revised assessment of multiple systematic reviews guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, injury characteristics, and operative details were extracted. Outcomes included patient reported outcome measures (PROMs), complications, and revision and return to sport (RTS) rates.

RESULTS

Twenty studies comprising 105 patients (119 knees) were included. Females comprised 10.1% (range: 0%-100%) of patients and the mean age of patients was 14.5 (range: 11-28) years. A total of 89 (74.7%) of knees received operative management, with 28 of 34 (82.4%) known open procedures being open reduction internal fixation (ORIF), and nine of 29 (31%) known arthroscopic procedures receiving arthroscopic reduction internal fixation (ARIF) or drilling. Lysholm and International Knee Documentation Committee scores in 20 patients each ranged from 93.4 to 100 and 74.7 to 96.6, respectively. The revision rate for operative procedures was 9.0%, and the overall RTS rate was 93.3%.

CONCLUSION

There is very little high quality evidence investigating patients with femoral trochlear OCD lesions. Drilling, ARIF, and ORIF were the most common surgical options for this patient population. Patients treated with either nonoperative or operative management returned to sport at a high rate, and those requiring operative management had a low revision rate.

LEVEL OF EVIDENCE

Level V.

Patella and Trochlea Osteochondritis Dissecans: Demographics and Treatment Paradigms

OBJECTIVE

Previous research on patellar and trochlear groove osteochondritis dissecans (OCD) is limited by small sample sizes. This study aims to describe the presentation of patients with OCD lesions of the patella and trochlea and characterize the outcomes of operative and nonoperative treatments.

METHODS

This retrospective cohort study identified all patients from a single institution from 2008 to 2021 with patellar and/or trochlear OCD lesions. Patients were excluded from the study if surgical records were unavailable or if the patient had knee surgery for a different injury at index surgery or in the 12 months postoperative. Minimum follow-up was 12 months. Outcomes included a return to sports (RTS), pain resolution, radiographic healing, and treatment "success" (defined as full RTS, complete pain resolution, and full healing on imaging).

RESULTS

A total of 68 patients (75 knees) were included-45 (60%) with patellar OCD and 30 (40%) with trochlear. Of the patients, 69% were males. The median age at knee OCD diagnosis was 14 years. At the final follow-up, 62% of knees (n = 44) recovered sufficiently to allow a full RTS and 54% of knees (n = 39) had full pain resolution. Of the 46 knees with radiographic imaging at least 1 year apart, 63% had full healing of the lesion. There was no significant difference in RTS, pain resolution, radiographic healing, or overall success when comparing treatments.

CONCLUSIONS

This study provides valuable epidemiologic demographic and outcome data regarding the scarcely reported patellar and trochlear OCD. While over half of patients fully returned to sports and reported full pain resolution, a large proportion continued to experience symptoms over a year after presentation. Future research should aim to better define the treatment algorithms for these OCD subtypes.

LEVEL OF EVIDENCE

Level III.

[Treatment of osteochondritis dissecans]

Osteochondritis dissecans (OD) is a rare condition with an incidence of 30/100,000. It especially affects male patients aged 10-20 years old. During the staged progression the osteochondral fragments can detach from their base. These can damage the adjacent articular cartilage, which can lead to premature osteoarthritis. Most commonly affected are the knee, ankle and elbow joints. The exact pathogenesis of OD has so far not been clearly confirmed. Several risk factors that can lead to the development of OD are discussed. These include repeated microtrauma and vascularization disorders that can lead to ischemia of the subchondral bone and to a separation of the fragments close to the joint and therefore to the development of free joint bodies. For an adequate clarification patients should undergo a thorough radiological evaluation including X‑ray imaging followed by magnetic resonance imaging (MRI) to assess the integrity of the cartilage-bone formation with determination of the OD stage. The assessment is based on criteria of the International Cartilage Repair Society (ICRS). The instability of the cartilage-bone fragment increases with higher stages. Stages I and II with stable cartilage-bone interconnection can be treated conservatively. For stages III and IV, i.e., instability of the OD fragment or the presence of free fragments, surgical treatment should be performed. Primarily, refixation of a free joint body should be carried out depending on the size and vitality of the fragment. In cases of unsuccessful conservative treatment or fixation, a debridement, if necessary in combination with a bone marrow stimulating procedure, can be employed corresponding to the size of the defect. For larger cartilage defects, an osteochondral graft transplantation should be considered. Overall, OD lesions in stages I and II show a good healing tendency under conservative treatment. In cases of incipient unstable OD, refixation can also lead to good clinical and radiological results.

S.P.O.R.R.T.-A Comprehensive Approach to the Assessment and Non-Operative Management of Overuse Knee Conditions in Youth Athletes

PURPOSE OF REVIEW

The evaluation of a young athlete with an overuse injury to the knee involves a comprehensive approach. There are a number of elements to consider including assessments of skeletal maturity (biologic maturation), workload (training load + competition load), sport specialization status, and biomechanics. The type of injury and treatment, as well as future prognosis, may be influenced by these and other factors.

RECENT FINDINGS

Calculating the percentage of predicted adult height (PPAH) is a valuable tool in assessing overuse injury patterns and diagnoses in youth athletes. Modifiable and non-modifiable overuse injury risk factors require monitoring from clinicians as young athletes mature and develop over time. Training and rehabilitation programs should be adapted to account for these. In this manuscript, we seek to introduce a novel, comprehensive approach: S.P.O.R.R.T. (Skeletal Maturity, Prior Injury Risk, One Sport Specialization, Rehabilitation, Return to Play, Training Recommendations) (Fig. 1). Overuse, non-traumatic injuries to the knee in youth athletes will be presented in a case-based and evidence-based model to provide a framework for a comprehensive approach to the assessment and treatment of youth athletes with overuse injuries.

Osteochondritis dissecans of the knee in adolescents: How to treat them?

Background

Osteochondritis dissecans is an acquired condition of the joint that affects the articular surface and the subchondral bone. The juvenile form of osteochondritis dissecans presents in those aged 5-16 years with open growth plates. The causes of osteochondritis dissecans are unknown.

Methods

The goals of treatment are to promote healing of the subchondral bone and prevent chondral collapse, subsequent fracture, osteochondral defect formation, and early joint degeneration. Treatment modality is influenced on clinical symptoms, skeletal maturity, as well as the size, stability, and location of the lesion. This article will review the treatment strategies of juvenile form of osteochondritis dissecans of medial femoral condyle and of atypical regions, such as lateral femoral condyle, patellofemoral joint, and tibial plateau.

Level of evidence

level III.

Osteochondritis Dissecans Lesions of the Pediatric and Adolescent Knee

Osteochondritis dissecans of the knee in pediatric and adolescent patients remains an incompletely understood entity, with multiple theories proposed for its underlying cause and variable treatment modalities. In addition to the importance of history and examination, treatment is primarily guided by lesion stability, which can be determined by MRI and arthroscopic findings. Other important factors that can influence healing include patient skeletal maturity, lesion location, and the size of the lesion. The purpose of this article is to review the most current epidemiology, classification, and pathoanatomy of the disease and discuss the different treatment options.

Incidence of Subsequent Surgical Intervention at Short-term Follow-up in Previously Healing and Stable Juvenile Osteochondritis Dissecans of the Knee

BACKGROUND

Juvenile osteochondritis dissecans (OCD) of the knee is a defect of subchondral bone seen primarily in active children and adolescents. Studies have evaluated the incidence of surgery in knee OCD, but the incidence of subsequent surgery in patients with stable, healing lesions cleared to return to activities is unknown. This study sought to determine the incidence of surgery in participants with knee OCD lesions cleared to return to activities and evaluate predictors of subsequent surgery.

METHODS

A single center, retrospective review was performed of participants aged 7 to 18 with knee OCD. Inclusion criteria were stable lesion, skeletal immaturity, no history of previous knee surgery, release to activity without surgery, and at least 12 months of follow-up. Documentation of subsequent surgery was queried in the electronic health record. Participants with no recorded surgery were contacted through phone. Analysis included bivariate and logistic regression.

RESULTS

Twenty-five individuals were included in this study, with 7 undergoing surgery after returning to activity. Medial femoral condyle lesions were less likely to undergo surgery (B=-2.6, P=0.038). Average lesion size for the Surgery and No Surgery groups was 1.76±0.65 and 1.32±0.81 cm2, respectively, though not significantly different (P=0.21). The Surgery group returned to activity sooner (3.7 mo, range 1.1 to 6.4) than the No Surgery group (8.1 mo, range 1.8 to 35.4), though not significantly different (P=0.18). Mean follow-up time for the study was 42.7 (range 12.6 to 77.6) months. No participants contacted by phone progressed to surgery or reported symptoms that limited their activities.

CONCLUSIONS

While the majority of participants with stable, healing, and asymptomatic knee OCD lesions have favorable outcomes with nonoperative management, some lesions may progress to surgery. Lesions on the medial femoral condyle may be predictive of lower likelihood of progression to surgery. Our study provides insight on the outcomes of nonoperative management of OCD lesions.

LEVEL OF EVIDENCE

Level IV-prognostic study.

Descriptive Epidemiology From the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort

BACKGROUND

Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease.

PURPOSE

To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest.

RESULTS

As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases.

CONCLUSION

The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.

What Do We Currently Know About Patellofemoral Osteochondritis Dissecans?

OBJECTIVE

Knee osteochondritis dissecans (OCD) is a still poorly understood pathological condition of the articular subchondral bone and its overlying cartilage. Patellofemoral involvement accounts for less than 1% of cases; tibial plateau and multifocal involvement is an even rarer instance. The purpose of this study is to review what is currently known about patellofemoral OCD (PF-OCD) and to present an unusual case of PF-OCD which progressed to become multifocal in an adult female patient.

METHODS

A comprehensive literature search was conducted on PubMed/Medline, Cochrane, Embase, Web of Science, and Scopus databases on September 2021 for all levels of evidence and English language. After duplicate removal, 234 papers pertaining to PF-OCD were retrieved. Thirty-nine studies met inclusion criteria and were included in the review. As an example, a unique case of delamination of patellar cartilage consistent with PF-OCD with progressive involvement of trochlea and both tibial plateau in a 35-year-old woman is also presented.

RESULTS

PF-OCD is a rare localization of knee OCD. Two hundred eighty-eight cases have been reported in the literature to date. Mean age at time of diagnosis was 16 years and the location could also be bilateral and multifocal. The etiology is still debated but traumatic, vascular, and hereditary mechanisms are likely. Management mirrors that of classical OCD.

CONCLUSIONS

PF-OCD is an uncommon cause of anterior knee pain but should be considered even when physeal plates are closed. Current available evidence on treatment is of low quality, based on single case reports or small retrospective case series.

Osteochondritis Dissecans Lesion of the Trochlear Groove: A Case of Nonsurgical Management for a Rare Lesion

Osteochondritis dissecans (OCD) lesions are potential causes of knee pain in pediatric patients, with lesions most frequently found on the lateral and medial femoral condyles. This case discusses an OCD lesion of the trochlear groove, a rare location for OCD lesions, in an 11-year-old female athlete. The patient presents after several years of knee pain that had acutely worsened, and both X-ray and MRI demonstrated the lesion, with MRI confirming a stable lesion. While previous literature has leaned towards surgical management, this patient was successfully managed nonoperatively in a locked knee brace for 12 weeks. She then went through 4 weeks of physical therapy and a 4 week progression back into soccer activity with return to full activity in 5 months.

Internal Fixation of Lateral Trochlear Groove Osteochondritis Dissecans With Simultaneous Lateral Retinacular Lengthening in Adolescent Athletes

BACKGROUND

The goals of operative treatment for the adolescent athlete with unstable osteochondritis dissecans (OCD) lesion are rigid fixation and prevention of recurrence.

PURPOSE

To evaluate clinical and radiological outcomes of internal fixation of lateral trochlear groove OCD with simultaneous lateral retinacular lengthening.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Adolescent athletes who had undergone internal fixation and simultaneous lateral retinacular lengthening for an unstable OCD lesion of the lateral trochlear groove were retrospectively reviewed. Subjective assessments included the Lysholm score, International Knee Documentation Committee (IKDC) subjective score, Tegner activity scale, and an athletic questionnaire. Functional tests included isokinetic muscle strength, single-leg hop for distance, single-leg vertical jump, and Y-balance. Pre- and postoperative radiographs and magnetic resonance images were reviewed.

RESULTS

The mean ± SD age of the 17 patients included in this study was 15.9 ± 0.9 years; last clinical follow-up duration was 37.7 ± 8.1 months. At the last follow-up, the Lysholm score improved from 68.7 ± 15.3 to 93.4 ± 12.4 and the IKDC subjective score from 60.2 ± 14.7 to 88.7 ± 12.7 (P < .001). The mean Tegner activity scale score was 9.4 ± 0.5 before injury and 8.9 ± 1.2 at the last follow-up (P = .059). The limb symmetry indices of isokinetic muscle strength, single-leg hop for distance, single-leg vertical jump, and Y-balance improved at the last follow-up; the mean limb symmetry index was ≥85% in each functional test. Regarding the athletic questionnaire, 16 (94.1%) patients were satisfied with the surgery. At the last follow-up, 2 patients had higher ability after returning to sports, 11 had the same ability, and 3 had lower ability than the preinjury level. Postoperative magnetic resonance imaging at 12-month follow-up showed that the OCD lesion appeared healed in 7 (41.2%) patients and partially healed in 9 (52.9%).

CONCLUSION

Internal fixation of lateral trochlear groove OCD with simultaneous lateral retinacular lengthening in adolescent athletes achieved satisfactory clinical and radiological outcomes. Therefore, this combined surgical technique could be considered an effective treatment for lateral trochlear groove OCD, with a high rate of return to sport.

Osteochondritis Dissecans: Current Understanding of Epidemiology, Etiology, Management, and Outcomes

➤

Osteochondritis dissecans occurs most frequently in the active pediatric and young adult populations, commonly affecting the knee, elbow, or ankle, and may lead to premature osteoarthritis.

➤

While generally considered an idiopathic phenomenon, various etiopathogenetic theories are being investigated, including local ischemia, aberrant endochondral ossification of the secondary subarticular physis, repetitive microtrauma, and genetic predisposition.

➤

Diagnosis is based on the history, physical examination, radiography, and advanced imaging, with elbow ultrasonography and novel magnetic resonance imaging protocols potentially enabling early detection and in-depth staging.

➤

Treatment largely depends on skeletal maturity and lesion stability, defined by the presence or absence of articular cartilage fracture and subchondral bone separation, as determined by imaging and arthroscopy, and is typically nonoperative for stable lesions in skeletally immature patients and operative for those who have had failure of conservative management or have unstable lesions.

➤

Clinical practice guidelines have been limited by a paucity of high-level evidence, but a multicenter effort is ongoing to develop accurate and reliable classification systems and multimodal decision-making algorithms with prognostic value.

Bilateral osteochondral defects of the patellae in an 11-year-old girl

Osteochondral defect or osteochondritis dissecans (OCD) of the knee usually affects young, active populations. It is a challenging diagnosis as patients typically present with poorly localised activity-related pain, which is non-specific and covers many differentials. We present an active 11-year-old girl with bilateral osteochondral defects of the patellae: a rare clinical disorder which was affecting her sporting activities. She had a 12-month history of bilateral anterior knee pain before the diagnosis was achieved with appropriate imaging. Her pain significantly improved with activity modification and physiotherapy. Follow-up will require outpatient clinic assessment and imaging to determine if non-operative management continues to be successful or surgery may be required. This case report emphasises the importance of appropriate high index of suspicion when managing patients with non-specific knee pain. It also demonstrates the importance of judicious use of imaging to avoid a missed or delayed diagnosis.

Juvenile Osteochondritis Dissecans of the Trochlea: A Cohort Study of 34 Trochlear Lesions Associated With Sporting Activities That Load the Patellofemoral Joint

BACKGROUND

Juvenile osteochondritis dissecans (JOCD) lesions are rarely located in the trochlea and few studies have focused on the causes and outcomes of JOCD lesions in this part of the knee. The purpose of this study is to (1) evaluate the clinical characteristics and outcomes of patients who undergo surgery for JOCD in this unusual location as well as (2) assess the association between trochlear JOCD and participation in sporting activities that load the patellofemoral joint.

METHODS

We conducted a retrospective cohort study of 34 trochlear JOCD lesions in 30 patients. Cases that involved traumatic cartilage shear or patella instability were excluded. Preoperative and postoperative magnetic resonance images and x-rays were evaluated and demographic data, sports played, comorbidities, surgical procedures, and clinical data were extracted from medical records. A case-control cohort of 102 femoral condyle lesions was used to assess the correlation between sports played and lesion location.

RESULTS

The cohort comprised 34 consecutive trochlear JOCD lesions in 30 patients (26 males, 4 females). Average age at surgery was 13.8 years (9.3 to 18.0 y). In total, 27 (90%) patients were active, and of these active patients, soccer and basketball were the most common sports played. In the case-control comparison, the correlation between playing either basketball or soccer and the presence of a trochlear JOCD lesion was statistically significant (P=0.017). In total, 21 knees (62%) received operative treatment. Sixteen of the surgical patients underwent repair and fixation with bioabsorbable nails. The average length of clinical and radiographic follow-up was 21.1 months. All patients who underwent fixation showed radiographic and/or clinical indications of healing at most recent follow-up. Thirteen of the patients who underwent fixation were active, and all of these patients reported successful return to sports. Thirteen knees underwent nonoperative treatment, and the majority of these patients had limited follow-up.

CONCLUSIONS

We report a significant association between pediatric athletes who play basketball and soccer and the development of trochlear JOCD, suggesting that repetitive loading of the patellofemoral joint may play a role in the development of JOCD lesions. Patients with trochlear JOCD lesions were likely to undergo surgery, and repair and fixation of the lesions produced good outcomes at short-term follow-up.

LEVEL OF EVIDENCE

Level III-case-control study.

Juvenile osteochondritis dissecans (JOCD) of the knee: current concepts review

Juvenile osteochondritis dissecans (JOCD) is a joint disorder of the subchondral bone and articular cartilage that affects skeletally immature patients.

The aetiology of JOCD is unknown and the natural history is poorly characterized in part due to inconsistent and largely retrospective literature.

Most OCD in children and adolescents presents as a stable lesion amenable to non-operative treatment or minimally invasive drilling. However, unstable forms can require a more aggressive approach.

This article reviews the most recent literature available and focuses on the pathophysiology, diagnosis and treatment of JOCD of the knee.

Cite this article: EFORT Open Rev 2019;4:201-212. DOI: 10.1302/2058-5241.4.180079

Sporadically occurred bilateral osteochondritis dissecans on the trochlea of the femur: case report

We report the case of a 13-year-old boy with bilateral osteochondritis dissecans in the lateral femoral trochlea of the knees. They were classified as grade 4 in the right knee and grade 1 in the left knee on the basis of the Nelson classification within 1 year after first consultation. In the right knee, the fragment was surgically fixed, but the left knee healed with conservative treatment. This case indicates the possibility that osteochondritis dissecans of the lateral femoral trochlea may develop bilaterally at different times and present at different stages. The case shows the importance of early diagnosis and appropriate treatment on the basis of the stage.

Osteochondritis Dissecans Involving the Trochlear Groove Treated With Retrograde Drilling: A Case Report

Osteochondritis dissecans (OCD) occurs frequently in the humeral capitellum of the upper extremity, whereas OCD involving the trochlear groove (trochlear groove OCD) is rarely reported. A standard treatment for trochlear groove OCD has therefore not been determined, although several methods have been tried.The case of a 14-year-old male gymnast with bilateral trochlear groove OCD is presented. Retrograde drilling from the lateral condyle of the humerus was applied for the OCD lesion of the left elbow, since it was larger in size than that in the right elbow and was symptomatic. Conversely, since the right lesion was small and asymptomatic, it was managed conservatively.After treatment, consolidation of the OCD lesions was observed in both elbows. However, the time to healing was shorter in the left elbow treated surgically than in the right elbow managed conservatively.In conclusion, retrograde drilling is a very simple and minimally invasive treatment. This case suggests that retrograde drilling for trochlear groove OCD may be a useful procedure that may accelerate the healing process for OCD lesions.